Ann Thorac Surg 2015;99:1051–3
5. 6. 7.
8.
CASE REPORTS MASSI ET AL BRONCHIAL ARTERY EMBOLIZATION
1051
postinfarction cardiac rupture. Echocardiography 2013;30: 106–13. Drago M, Butera G, Giamberti A, Lucente M, Frigiola A. Interventricular septal hematoma in ventricular septal defect patch closure. Ann Thorac Surg 2005;79:1764–5. Mart CR, Kaza AK. Postoperative dissecting ventricular septal hematoma: recognition and treatment. ISRN Pediatr 2011;2011:534940. Ettles DF, Firth N, Nair RU, Williams GJ. Fatal acute left ventricular outflow obstruction due to interventricular septal haematoma—diagnosis by transoesophageal echocardiography. Eur Heart J 1989;10:479–81. Prashanth P, Mukhaini M, Maddali MM. Intramyocardial dissecting haematoma causing cardiac tamponade: an unusual complication after mitral valve replacement surgery. Ann Card Anaesth 2009;12:79–80.
Myocardial Infarction and Rupture After Bronchial Artery Embolization
Cardiac Surgery Department and Cardiology Department, Ospedale Civile Santissima Annunziata, Sassari, Italy
Bronchial artery embolization is a well-known treatment for hemoptysis. Adverse events of this procedure include multiple systemic embolism and infarction. Myocardial infarction has been recently reported during bronchial artery embolization, owing to the presence of a coronaryto-bronchial artery fistula. We report the management of an ischemic left ventricular free wall rupture caused by bronchial artery embolization in a patient with massive hemoptysis, bronchiectasis, and undetected coronary-to-bronchial artery anomalous connection. (Ann Thorac Surg 2015;99:1051–3) Ó 2015 by The Society of Thoracic Surgeons
B
ronchial artery embolization is a well-known and effective treatment for hemoptysis. Adverse events of this procedure include chest pain, dysphagia, esophageal fistula, arterial injury, multiple systemic embolism, and spinal cord or brain infarctions [1]. Myocardial infarction after bronchial artery embolization has been recently reported to be caused by embolization of the left coronary artery resulting from a coronaryto-bronchial artery fistula [2]. We report the successful surgical treatment of an ischemic left ventricular free wall rupture caused by bronchial artery embolization in a patient with massive hemoptysis, bronchiectasis, and undetected coronary-to-bronchial artery anomalous connection.
Accepted for publication April 23, 2014. Address correspondence to Dr Massi, Cardiac Surgery, Ospedale Civile S.S. Annunziata, Via De Nicola No. 1, 07100 Sassari, Italy; e-mail: [email protected].
Ó 2015 by The Society of Thoracic Surgeons Published by Elsevier
Fig 1. Computed tomographic view of the left lung lower lobe and lingula consolidation (white arrow).
A 75-year-old woman came to at the emergency department with massive hemoptysis, hypotension, and fever. Her medical history was positive for bronchiectasis and recurrent hemoptysis, severe peripheral artery disease, and previous left carotid artery thromboendarterectomy. Blood tests revealed a high white blood cell count and severe anemia. Roentgenology and computed tomography (CT) of the chest revealed left lung lower lobe and lingula consolidation (Fig 1). The patient underwent blood transfusions and urgent bronchial arteriography, followed by a super selective embolization of a bronchial artery feeding the left lung lingula that had a chronic infective aspect and tortuous arterial vascularization. The procedure used compressible hydrogel microspheres of 100 to 300 mm produced from polyvinyl alcohol (Bead Block, Biocompatibles UK Ltd, Farnham, UK). At the end of the embolization procedure, the patient showed signs of bradycardia and arterial hypotension, and the electrocardiogram showed ST elevation in DII, DIII, AVF, and ST depression in anterior leads. Coronary angiography revealed no stenosis of the right coronary artery or of its branches (Fig 2), but it did show stasis (no-washout) of contrast medium in the right posterolateral branch (RPL) caused by microembolism and occlusion of coronary microcirculation in the RPL perfusion territory (Fig 3). Ten hours later, troponinemia increased to 47.8 ng/mL. The patient was tachycardic and hypotensive. Transthoracic echocardiography revealed a 35-mm pericardial effusion at the level of the free wall of the right ventricle and cardiac apex. The patient underwent emergency sternotomy for hemodynamic shock and suspected cardiac rupture. The procedure was performed on a beating heart and with extracorporeal circulation. Myocardial examination revealed a breach 1 cm long in the middle portion of the inferior part of the left ventricle surrounded by infarcted 0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2014.04.139
FEATURE ARTICLES
Francesco Massi, MD, Mirko Muretti, MD, Enrico Coradduzza, MD, Carlo Poddighe, MD, Pierfranco Terrosu, MD, and Michele Portoghese, MD
FEATURE ARTICLES
1052
CASE REPORTS MASSI ET AL BRONCHIAL ARTERY EMBOLIZATION
Fig 2. Coronary angiographic view of the right coronary artery and its branches (descending posterior, right posterolateral) without severe stenotic lesions.
myocardial tissue (Fig 4). The rupture was repaired with Prolene U stiches reinforced with Teflon, a pericardial patch, and biologic glue. An intra-aortic balloon pump was positioned through the ascending aorta because of severe peripheral arterial disease. The postoperative period in the intensive care unit was 16 days long and was complicated by pulmonary infection. The patient was discharged on the 34th postoperative day. Six months after the procedures, she was asymptomatic, in New York Heart Association class II, and in good clinical condition. She had no further hemoptysis, and transthoracic echocardiography revealed a
Fig 3. Coronary angiographic view of stasis of contrast medium in the right posterolateral branch (white arrow), resulting from microembolism and occlusion of coronary microcirculation in the posterolateral branch perfusion territory.
Ann Thorac Surg 2015;99:1051–3
Fig 4. Myocardial breach in the middle portion of inferior part of left ventricle surrounded by infarcted myocardial tissue (encircled by white line).
left ventricle ejection fraction of 45% and mild mitral and tricuspid valve insufficiency.
Comment Myocardial infarction after bronchial artery embolization for hemoptysis has been recently reported. Qiu and Dong [2] describe embolization of the left coronary artery because of a coronary-to-bronchial artery fistula that was not opacified during bronchial angiography, owing to the higher pressure of coronary artery circulation. The incidence of coronary-to-bronchial artery anastomosis varies from 0.08% to 0.61%, but the real incidence is underestimated [3]. Small anastomoses have been noted to occur in about 20% of normal individuals in the absence of other abnormalities. Coronary-to-bronchial anastomoses may be present at birth and remain closed and asymptomatic, owing to the similarity of filling pressures of the coronary and bronchial circulation. Larger shunts have been demonstrated in significant coronary artery disease (the bronchial arteries may communicate by collaterals with the coronary artery distal to the site of obstruction). Shunts may be also present in severe right ventricular outflow tract obstructions (pulmonary thromboembolism, pulmonary artery tumor, tetralogy of Fallot) or in cases of chronic pulmonary inflammatory disease such as bronchiectasis, Takayasu arteritis, and tuberculosis (the coronary arteries may communicate through collaterals with the pulmonary circulation at a lower perfusion pressure) [4, 5]. Previous studies have shown the relationship between bronchiectasis and coronary-to-bronchial artery fistulas [6]. The feeding arteries of the coronary-to-bronchial artery anastomosis include the left atrial branches, sinus node branches, conal branches, and posterolateral branches [4].
Ann Thorac Surg 2015;99:1053–5
The authors thank Dr Luca Sammartino and Mike Robinson for proofreading.
1053
2. Qiu MJ, Dong DJ. Myocardial infarction following bronchial artery embolization for hemoptysis. Chin Med J (Engl) 2013;126:997. 3. Lee ST, Kim SY, Hur G, et al. Coronary-to-bronchial artery fistula: demonstration by 64-multidetector computed tomography with retrospective electrocardiogram-gated reconstructions. J Comput Assist Tomogr 2008;32:444–7. 4. Matsunaga N, Hayashi K, Sakamoto I, et al. Coronary-topulmonary artery shunts via the bronchial artery: analysis of cineangiographic studies. Radiology 1993;186:877–82. 5. Bj€ ork L. Angiographic demonstration of extracardiac anastomoses to the coronary arteries. Radiology 1966;87:274–7. 6. Jim MH, Lee SW, Lam L. Localized bronchiectasis is a definite association of coronaro-bronchial artery fistula. J Invasive Cardiol 2003;15:554–6. 7. Peynircioglu B, Ergun O, Hazirolan T, Cil BE, Aytemir K. Bronchial to coronary artery fistulas: an important sign of silent coronary artery disease and potential complication during bronchial artery embolization. Acta Radiol 2007;48:171–2. 8. Shin KC, Shin MS, Park JW, et al. Prophylactic and therapeutic embolization of coronary-bronchial artery fistula in patient with bronchiectasis. Int J Cardiol 2011; 151:e71–3.
Damaged Right Internal Jugular Venous Catheter Status After Cox Maze IV Procedure Shannon Kim, MD, Harlan Vingan, MD, and Jonathan Philpott, MD Departments of Radiology and Cardiothoracic Surgery, Eastern Virginia Medical School, Norfolk, Virginia
The Cox-Maze IV (CM-IV) procedure was introduced as a modification of the Cox-Maze III by using a bipolar radiofrequency clamp to replicate the majority of the long linear cut and sew lesions. The CM-IV maintained excellent success rates with low complication, and there are no reports of device-related complication in the literature. In this article, we present a patient who underwent aortic valve replacement with a concomitant CM-IV procedure. There was difficulty removing the right internal jugular catheter during the postoperative course, with evidence of catheter fracture on chest radiograph. Upon catheter removal by Interventional Radiology, the distal segment had sustained a radiofrequency burn strike that had melted the involved segment with significant loss of catheter integrity. Of the several events that have occurred in our high volume Maze program, this resulted in changing the anesthesia protocol by using shorter catheters that will be less likely to become caught in the jaws of the bipolar clamp during the performance of the intercaval line of the CM-IV. (Ann Thorac Surg 2015;99:1053–5) Ó 2015 by The Society of Thoracic Surgeons
References 1. Pestana Knight EM, Novelli PM, Joshi SM. Cerebral and systemic infarcts after bronchial artery embolization. Pediatr Neurol 2011;45:324–7. Ó 2015 by The Society of Thoracic Surgeons Published by Elsevier
Accepted for publication April 21, 2014. Address correspondence to Dr Kim, Department of Radiology, 600 Gresham Dr, Norfolk, VA 23510; e-mail: [email protected].
0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2014.04.133
FEATURE ARTICLES
Many authors focus on the possibility of embolic material regurgitation from the bronchial artery to the coronary artery during bronchial embolization in cases of coronary-to-bronchial anastomosis not previously detected [7]. The diagnosis of coronary-to-bronchial artery anomalous connections requires contrast-enhanced multidetector CT with retrospective electrocardiographic gating [3]. Functional tests including myocardial perfusion scanning or coronary angiography before bronchial embolization could be helpful in the diagnosis of coronary-to-bronchial artery fistula [8]. In this case, the coronary-to-bronchial anastomosis was not detected by bronchial artery angiography. Probably there was no shunt between coronary and bronchial arteries, owing to similar filling pressures of the coronary and bronchial circulations [2]. Before embolization, the patient underwent thoracic CT without retrospective electrocardiographic gating, addressed to visualization of the pulmonary parenchyma. Coronary angiography was performed only after the embolization of the bronchial artery and coronary-to-bronchial anastomosis. We suppose that the acute myocardial infarction and rupture were determined by a severe and diffuse iatrogenic microembolism and occlusion of coronary microcirculation in the RPL perfusion territory. Bronchial embolization was performed with a super selective catheter (0.010 inch, 0.25 mm) and with use of the smallest compressible hydrogel microspheres produced from polyvinyl alcohol (100–300 mm). The diffusion of microspheres through the coronary-to-bronchial artery anastomosis into the coronary microcirculation was probably caused by the high pressure of injection of the angiographic procedure. The reason for proceeding with medical therapy rather than a bypass operation or catheter-based treatment was the absence of significant stenosis in the lumen of the right coronary artery and its main branches. Because of the physical and chemical properties of the microspheres, fibrinolysis would not have been useful. We advocate a high level of awareness for coronaryto-bronchial anastomosis in patients with chronic pulmonary inflammatory disease. Coronary angiography and contrast-enhanced multidetector CT with retrospective electrocardiographic gating may help clinicians detect coronary-to-bronchial anastomosis. The use of larger microspheres may avoid regrettable complications during interventional procedures in the presence of coronary-to-bronchial anastomosis. The possibility of performing a procedure in a hybrid operating room might be safer for these specific patients.
CASE REPORTS KIM ET AL DAMAGED RIJV CATHETER STATUS AFTER COX-MAX IV
5. 6. 7.
8.
CASE REPORTS MASSI ET AL BRONCHIAL ARTERY EMBOLIZATION
1051
postinfarction cardiac rupture. Echocardiography 2013;30: 106–13. Drago M, Butera G, Giamberti A, Lucente M, Frigiola A. Interventricular septal hematoma in ventricular septal defect patch closure. Ann Thorac Surg 2005;79:1764–5. Mart CR, Kaza AK. Postoperative dissecting ventricular septal hematoma: recognition and treatment. ISRN Pediatr 2011;2011:534940. Ettles DF, Firth N, Nair RU, Williams GJ. Fatal acute left ventricular outflow obstruction due to interventricular septal haematoma—diagnosis by transoesophageal echocardiography. Eur Heart J 1989;10:479–81. Prashanth P, Mukhaini M, Maddali MM. Intramyocardial dissecting haematoma causing cardiac tamponade: an unusual complication after mitral valve replacement surgery. Ann Card Anaesth 2009;12:79–80.
Myocardial Infarction and Rupture After Bronchial Artery Embolization
Cardiac Surgery Department and Cardiology Department, Ospedale Civile Santissima Annunziata, Sassari, Italy
Bronchial artery embolization is a well-known treatment for hemoptysis. Adverse events of this procedure include multiple systemic embolism and infarction. Myocardial infarction has been recently reported during bronchial artery embolization, owing to the presence of a coronaryto-bronchial artery fistula. We report the management of an ischemic left ventricular free wall rupture caused by bronchial artery embolization in a patient with massive hemoptysis, bronchiectasis, and undetected coronary-to-bronchial artery anomalous connection. (Ann Thorac Surg 2015;99:1051–3) Ó 2015 by The Society of Thoracic Surgeons
B
ronchial artery embolization is a well-known and effective treatment for hemoptysis. Adverse events of this procedure include chest pain, dysphagia, esophageal fistula, arterial injury, multiple systemic embolism, and spinal cord or brain infarctions [1]. Myocardial infarction after bronchial artery embolization has been recently reported to be caused by embolization of the left coronary artery resulting from a coronaryto-bronchial artery fistula [2]. We report the successful surgical treatment of an ischemic left ventricular free wall rupture caused by bronchial artery embolization in a patient with massive hemoptysis, bronchiectasis, and undetected coronary-to-bronchial artery anomalous connection.
Accepted for publication April 23, 2014. Address correspondence to Dr Massi, Cardiac Surgery, Ospedale Civile S.S. Annunziata, Via De Nicola No. 1, 07100 Sassari, Italy; e-mail: [email protected].
Ó 2015 by The Society of Thoracic Surgeons Published by Elsevier
Fig 1. Computed tomographic view of the left lung lower lobe and lingula consolidation (white arrow).
A 75-year-old woman came to at the emergency department with massive hemoptysis, hypotension, and fever. Her medical history was positive for bronchiectasis and recurrent hemoptysis, severe peripheral artery disease, and previous left carotid artery thromboendarterectomy. Blood tests revealed a high white blood cell count and severe anemia. Roentgenology and computed tomography (CT) of the chest revealed left lung lower lobe and lingula consolidation (Fig 1). The patient underwent blood transfusions and urgent bronchial arteriography, followed by a super selective embolization of a bronchial artery feeding the left lung lingula that had a chronic infective aspect and tortuous arterial vascularization. The procedure used compressible hydrogel microspheres of 100 to 300 mm produced from polyvinyl alcohol (Bead Block, Biocompatibles UK Ltd, Farnham, UK). At the end of the embolization procedure, the patient showed signs of bradycardia and arterial hypotension, and the electrocardiogram showed ST elevation in DII, DIII, AVF, and ST depression in anterior leads. Coronary angiography revealed no stenosis of the right coronary artery or of its branches (Fig 2), but it did show stasis (no-washout) of contrast medium in the right posterolateral branch (RPL) caused by microembolism and occlusion of coronary microcirculation in the RPL perfusion territory (Fig 3). Ten hours later, troponinemia increased to 47.8 ng/mL. The patient was tachycardic and hypotensive. Transthoracic echocardiography revealed a 35-mm pericardial effusion at the level of the free wall of the right ventricle and cardiac apex. The patient underwent emergency sternotomy for hemodynamic shock and suspected cardiac rupture. The procedure was performed on a beating heart and with extracorporeal circulation. Myocardial examination revealed a breach 1 cm long in the middle portion of the inferior part of the left ventricle surrounded by infarcted 0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2014.04.139
FEATURE ARTICLES
Francesco Massi, MD, Mirko Muretti, MD, Enrico Coradduzza, MD, Carlo Poddighe, MD, Pierfranco Terrosu, MD, and Michele Portoghese, MD
FEATURE ARTICLES
1052
CASE REPORTS MASSI ET AL BRONCHIAL ARTERY EMBOLIZATION
Fig 2. Coronary angiographic view of the right coronary artery and its branches (descending posterior, right posterolateral) without severe stenotic lesions.
myocardial tissue (Fig 4). The rupture was repaired with Prolene U stiches reinforced with Teflon, a pericardial patch, and biologic glue. An intra-aortic balloon pump was positioned through the ascending aorta because of severe peripheral arterial disease. The postoperative period in the intensive care unit was 16 days long and was complicated by pulmonary infection. The patient was discharged on the 34th postoperative day. Six months after the procedures, she was asymptomatic, in New York Heart Association class II, and in good clinical condition. She had no further hemoptysis, and transthoracic echocardiography revealed a
Fig 3. Coronary angiographic view of stasis of contrast medium in the right posterolateral branch (white arrow), resulting from microembolism and occlusion of coronary microcirculation in the posterolateral branch perfusion territory.
Ann Thorac Surg 2015;99:1051–3
Fig 4. Myocardial breach in the middle portion of inferior part of left ventricle surrounded by infarcted myocardial tissue (encircled by white line).
left ventricle ejection fraction of 45% and mild mitral and tricuspid valve insufficiency.
Comment Myocardial infarction after bronchial artery embolization for hemoptysis has been recently reported. Qiu and Dong [2] describe embolization of the left coronary artery because of a coronary-to-bronchial artery fistula that was not opacified during bronchial angiography, owing to the higher pressure of coronary artery circulation. The incidence of coronary-to-bronchial artery anastomosis varies from 0.08% to 0.61%, but the real incidence is underestimated [3]. Small anastomoses have been noted to occur in about 20% of normal individuals in the absence of other abnormalities. Coronary-to-bronchial anastomoses may be present at birth and remain closed and asymptomatic, owing to the similarity of filling pressures of the coronary and bronchial circulation. Larger shunts have been demonstrated in significant coronary artery disease (the bronchial arteries may communicate by collaterals with the coronary artery distal to the site of obstruction). Shunts may be also present in severe right ventricular outflow tract obstructions (pulmonary thromboembolism, pulmonary artery tumor, tetralogy of Fallot) or in cases of chronic pulmonary inflammatory disease such as bronchiectasis, Takayasu arteritis, and tuberculosis (the coronary arteries may communicate through collaterals with the pulmonary circulation at a lower perfusion pressure) [4, 5]. Previous studies have shown the relationship between bronchiectasis and coronary-to-bronchial artery fistulas [6]. The feeding arteries of the coronary-to-bronchial artery anastomosis include the left atrial branches, sinus node branches, conal branches, and posterolateral branches [4].
Ann Thorac Surg 2015;99:1053–5
The authors thank Dr Luca Sammartino and Mike Robinson for proofreading.
1053
2. Qiu MJ, Dong DJ. Myocardial infarction following bronchial artery embolization for hemoptysis. Chin Med J (Engl) 2013;126:997. 3. Lee ST, Kim SY, Hur G, et al. Coronary-to-bronchial artery fistula: demonstration by 64-multidetector computed tomography with retrospective electrocardiogram-gated reconstructions. J Comput Assist Tomogr 2008;32:444–7. 4. Matsunaga N, Hayashi K, Sakamoto I, et al. Coronary-topulmonary artery shunts via the bronchial artery: analysis of cineangiographic studies. Radiology 1993;186:877–82. 5. Bj€ ork L. Angiographic demonstration of extracardiac anastomoses to the coronary arteries. Radiology 1966;87:274–7. 6. Jim MH, Lee SW, Lam L. Localized bronchiectasis is a definite association of coronaro-bronchial artery fistula. J Invasive Cardiol 2003;15:554–6. 7. Peynircioglu B, Ergun O, Hazirolan T, Cil BE, Aytemir K. Bronchial to coronary artery fistulas: an important sign of silent coronary artery disease and potential complication during bronchial artery embolization. Acta Radiol 2007;48:171–2. 8. Shin KC, Shin MS, Park JW, et al. Prophylactic and therapeutic embolization of coronary-bronchial artery fistula in patient with bronchiectasis. Int J Cardiol 2011; 151:e71–3.
Damaged Right Internal Jugular Venous Catheter Status After Cox Maze IV Procedure Shannon Kim, MD, Harlan Vingan, MD, and Jonathan Philpott, MD Departments of Radiology and Cardiothoracic Surgery, Eastern Virginia Medical School, Norfolk, Virginia
The Cox-Maze IV (CM-IV) procedure was introduced as a modification of the Cox-Maze III by using a bipolar radiofrequency clamp to replicate the majority of the long linear cut and sew lesions. The CM-IV maintained excellent success rates with low complication, and there are no reports of device-related complication in the literature. In this article, we present a patient who underwent aortic valve replacement with a concomitant CM-IV procedure. There was difficulty removing the right internal jugular catheter during the postoperative course, with evidence of catheter fracture on chest radiograph. Upon catheter removal by Interventional Radiology, the distal segment had sustained a radiofrequency burn strike that had melted the involved segment with significant loss of catheter integrity. Of the several events that have occurred in our high volume Maze program, this resulted in changing the anesthesia protocol by using shorter catheters that will be less likely to become caught in the jaws of the bipolar clamp during the performance of the intercaval line of the CM-IV. (Ann Thorac Surg 2015;99:1053–5) Ó 2015 by The Society of Thoracic Surgeons
References 1. Pestana Knight EM, Novelli PM, Joshi SM. Cerebral and systemic infarcts after bronchial artery embolization. Pediatr Neurol 2011;45:324–7. Ó 2015 by The Society of Thoracic Surgeons Published by Elsevier
Accepted for publication April 21, 2014. Address correspondence to Dr Kim, Department of Radiology, 600 Gresham Dr, Norfolk, VA 23510; e-mail: [email protected].
0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2014.04.133
FEATURE ARTICLES
Many authors focus on the possibility of embolic material regurgitation from the bronchial artery to the coronary artery during bronchial embolization in cases of coronary-to-bronchial anastomosis not previously detected [7]. The diagnosis of coronary-to-bronchial artery anomalous connections requires contrast-enhanced multidetector CT with retrospective electrocardiographic gating [3]. Functional tests including myocardial perfusion scanning or coronary angiography before bronchial embolization could be helpful in the diagnosis of coronary-to-bronchial artery fistula [8]. In this case, the coronary-to-bronchial anastomosis was not detected by bronchial artery angiography. Probably there was no shunt between coronary and bronchial arteries, owing to similar filling pressures of the coronary and bronchial circulations [2]. Before embolization, the patient underwent thoracic CT without retrospective electrocardiographic gating, addressed to visualization of the pulmonary parenchyma. Coronary angiography was performed only after the embolization of the bronchial artery and coronary-to-bronchial anastomosis. We suppose that the acute myocardial infarction and rupture were determined by a severe and diffuse iatrogenic microembolism and occlusion of coronary microcirculation in the RPL perfusion territory. Bronchial embolization was performed with a super selective catheter (0.010 inch, 0.25 mm) and with use of the smallest compressible hydrogel microspheres produced from polyvinyl alcohol (100–300 mm). The diffusion of microspheres through the coronary-to-bronchial artery anastomosis into the coronary microcirculation was probably caused by the high pressure of injection of the angiographic procedure. The reason for proceeding with medical therapy rather than a bypass operation or catheter-based treatment was the absence of significant stenosis in the lumen of the right coronary artery and its main branches. Because of the physical and chemical properties of the microspheres, fibrinolysis would not have been useful. We advocate a high level of awareness for coronaryto-bronchial anastomosis in patients with chronic pulmonary inflammatory disease. Coronary angiography and contrast-enhanced multidetector CT with retrospective electrocardiographic gating may help clinicians detect coronary-to-bronchial anastomosis. The use of larger microspheres may avoid regrettable complications during interventional procedures in the presence of coronary-to-bronchial anastomosis. The possibility of performing a procedure in a hybrid operating room might be safer for these specific patients.
CASE REPORTS KIM ET AL DAMAGED RIJV CATHETER STATUS AFTER COX-MAX IV
